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African Harm Reduction Exchange - Dec 2022

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Clive Bates
Clive Bates

The science behind Tobacco Harm Reduction and how it impacts policy development and regulation 1. Smoking is the main problem 2. Smokefree products and science 3. Policy and unintended consequences 4. Innovation (and its enemies)

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Clive Bates Counterfactual 1 Nairobi 1 December 2022 Science behind Tobacco Harm Reduction and how it impacts policy development and regulation The Harm Reduction Exchange 2022
2 I am a former director of Action on Smoking and Health (UK) I have supported tobacco harm reduction since 1997 I have no competing interests with respect to the tobacco, e- cigarette, or pharmaceutical industries
Regulation for tobacco harm reduction 1. The problem is smoking 3
Well researched toll of harm from smoking Smoking prematurely kills around 8 million annually more than obesity, alcohol, road accidents, drug misuse and HIV combined 4 Public Health England, Health Matters similar to COVID-19, but every year
Smoking prevalence in Africa WHO (2021) 5 Published November 2021 South Africa Nigeria Ethiopia
Smoking prevalence in Africa WHO (2021) 6 Published November 2021 South Africa Ethiopia Nigeria
Declining prevalence but increasing population will increase African share 7 Africa
Regulation for tobacco harm reduction 1. The problem is smoking 2. Smoke-free alternatives 8
People smoke for the nicotine but die from the tar (1976) Professor Michael Russell 1932-2009 The central insight in smoking and health 9 Russell MJ. Low-tar medium nicotine cigarettes: a new approach to safer smoking. BMJ 1976;1:14303
Smokeless tobacco Tobacco based Pure nicotine based Heated aerosol Unheated Vaping products Heated tobacco products Heat-not-burn Items are not shown to scale Oral nicotine products 10
Royal College of Physicians on relative risk "Although it is not possible to precisely quantify the long- term health risks associated with e-cigarettes, the available data suggest that they are unlikely to exceed 5% of those associated with smoked tobacco products, and may well be substantially lower than this figure". 11 Royal College of Physicians. Nicotine without smoke: tobacco harm reduction London: RCP; 2016.
Department of Health (England) on relative risk September 2022 12 McNeill et al. Nicotine Vaping in England, 2022 vaping poses only a small fraction of the risks of smoking
Much lower Much lower Much lower Much lower Much lower Much lower The strongest evidence for reduced harm is reduced exposure 13 Shahab L, Goniewicz ML, Blount BC, et al. Nicotine, Carcinogen, and Toxin Exposure in Long-Term E-Cigarette and Nicotine Replacement Therapy Users. Ann Intern Med 2017
Evidence from randomised controlled trials 14 There is highcertainty evidence that e- cigarettes with nicotine increase quit rates compared to NRT
Evidence for beneficial population effect triangulates Also, user testimony And it is what you would expect!! 15 Professor Robert West, UCL. Presentation at SRNT-Europe 2019
Regulation for tobacco harm reduction 1. The problem is smoking 2. Smoke-free alternatives 3. Policy and unintended consequences 16
The public health mechanism 17
Royal College of Physicians perverse unintended consequences 18 Royal College of Physicians. Nicotine without smoke: tobacco harm reduction London: RCP; 2016.
if a risk-averse, precautionary approach makes e-cigarettes: less easily accessible less palatable or acceptable more expensive less consumer friendly pharmacologically less effective inhibits innovation then it causes harm by perpetuating smoking. Royal College of Physicians perverse unintended consequences 19 Royal College of Physicians. Nicotine without smoke: tobacco harm reduction London: RCP; 2016.
1. Prohibition of vaping and other smokefree products
1. Prohibition of vaping and other smokefree products Dr Harsh Vardhan received the award for spearheading the Government of Indias legislation to ban e-cigarettes and heated tobacco products in 2019.
1. Prohibition of vaping and other smokefree products 22 Today, the country is faced with a greater challenge, that of illegal traffic in tobacco and its products. So long as the demand within the country persists, it will continue to fuel the illicit market that has expanded since the ban of its sale in early 2000. Unfortunately, as studies indicate, Bhutanese youth are at the centre of this growing illegal trade in tobacco and its products. WHO Office Bhutan: The Big Ban: Bhutans journey towards a tobacco-free society, 2019
2. Banning e-liquid flavours 23
2. Banning e-liquid flavours Tobacco Fruit Dessert or pastry Choc, sweets Russell et al. vaping flavour preferences Russell C, et al. Changing patterns of first e-cigarette flavor used and current flavors used by 20,836 adult frequent e-cigarette users in the USA. Harm Reduct J. BioMed Central; 2018 24
2. Banning e-liquid flavours 25 The intended outcome: abstinence from nicotine, vaping, smoking and any other vice Using tobacco flavoured vape products instead of other flavoured products Accessing flavoured vapes via an illicit supply chain (a black market) Relapsing back from vaping to smoking both teenagers and adults Not switching from smoking to vaping and continuing to smoke Continuing to smoke or to start smoking as an adolescent because parents or adult role models smoke instead of vaping Using other tobacco or nicotine products hand-rolling tobacco, smokeless tobacco, heated tobacco, or new nicotine pouches Buying from foreign suppliers in person or via the internet and importing for personal use Buying from foreign suppliers to resell to others through informal networks Making and mixing their own flavours at home or buying or selling home-mixed flavours Using vapes that are made to look tobacco flavoured but have other flavours Using flavour agents for food, drink or aromatherapy for adding to unflavoured nicotine liquids Using flavours made for vaping but ostensibly marketed for another purpose Switching to cannabinoid (THC or CBD) vapes Initiating smoking instead of initiating vaping Adopting another risk behaviour that may be worse
Friedman AS. A Difference-in-Differences Analysis of Youth Smoking and a Ban on Sales of Flavored Tobacco Products in San Francisco, California. JAMA Pediatrics. 2021 2. Banning e-liquid flavours Teenage smoking increased following an e-cigarette flavours ban in San Francisco Past-30-Day Smoking Trends Among High School Students Younger Than 18 Years
3. Banning advertising of vapes 27
3. Banning advertising of vapes 28
3. Banning advertising of vapes 29 Dont be socially irresponsible Dont target or feature children Dont confuse e-cigarettes with tobacco products Dont make health or safety claims Dont make smoking cessation claims Dont mislead about product ingredients Dont mislead about where products may be use Set standards avoid bans
4. Fear-based warnings This product contains nicotine which is a highly addictive substance. 30 Required by EU Tobacco Products Directive 40/14/EU
4. Fear-based warnings [Our findings] suggest that the TPD nicotine addiction e-cigarette health warning may reduce smokers' willingness to use, and likelihood of purchasing an e- cigarette. 31 Cox S, et al Messages matter: The Tobacco Products Directive nicotine addiction health warning versus an alternative relative risk message on smokers willingness to use and purchase an electronic cigarette. Addict Behav Reports, 2018
This product is likely to be at least 95% safer than smoking cigarettes No product is completely safe, but use of this product is much less harmful than smoking 4. Fear-based warnings 32
5. Taxing safer products
5. Taxing safer products Reduce teen e-cigarette use by 2.7 percentage points, but that 2 in 3 teens who do not use e- cigarettes due to the tax would smoke cigarettes instead. .approximately a half million extra teenage smokers overall. raise the number of daily adult cigarette smokers by 2.5 million nationally and reduce adult e-cigarette users by a similar number. For every e-cigarette pod eliminated by an e- cigarette tax, more than 5.5 extra packs of cigarettes are sold instead Congress: raise e-cigarette taxes to a level comparable to cigarette taxes
5. Taxing safer products
The solution: Risk-Proportionate Regulation Measure Cigarettes, hand-rolling tobacco and other combustibles Taxation Relatively high taxes Advertising Prohibit other than within trade Warnings Graphic warnings depicting disease Public places Legally mandated controls Plain packaging Yes Ingredients Control reward-enhancing additives Age restrictions No sales to under-21s Internet sales Banned Product standards Control risks and reduce appeal 36
The solution: Risk-Proportionate Regulation Measure Cigarettes, hand-rolling tobacco and other combustibles Vaping, heated tobacco smokeless and oral nicotine Taxation Relatively high taxes Low or zero tax (sales tax only) Advertising Prohibit other than within trade Control themes and placement Warnings Graphic warnings depicting disease Messages encouraging switching Public places Legally mandated controls Up to the discretion of the owner Plain packaging Yes No Ingredients Control reward-enhancing additives Blacklist material health hazards Age restrictions No sales to under-21s No sales to under-18s Internet sales Banned Permitted with age controls Product standards Control risks and reduce appeal Control risks 37
Regulations for tobacco harm reduction 1. The problem is smoking 2. Smoke-free alternatives 3. Policy and unintended consequences 4. Innovation (and its enemies) 38
A technology transition - cars
A technology transition - electricity
Innovation and its enemies Claims about the promise of new technology are at times greeted with skepticism, vilification or outright oppositionoften dominated by slander, innuendo, scare tactics, conspiracy theories and misinformation. The assumption that new technologies carry unknown risks guides much of the debate. This is often amplified to levels that overshadow the dangers of known risks. Juma C. Innovation and Its Enemies: Why People Resist New Technologies. Oxford, New York: Oxford University Press; 2016.
Thankyou! Counterfactual clivedbates@gmail.com www.clivebates.com @clive_bates 1. The problem is smoking 2. Smoke-free alternatives 3. Policy and unintended consequences 4. Innovation (and its enemies) Regulation for tobacco harm reduction

More Related Content

African Harm Reduction Exchange - Dec 2022

  • 1. Clive Bates Counterfactual 1 Nairobi 1 December 2022 Science behind Tobacco Harm Reduction and how it impacts policy development and regulation The Harm Reduction Exchange 2022
  • 2. 2 I am a former director of Action on Smoking and Health (UK) I have supported tobacco harm reduction since 1997 I have no competing interests with respect to the tobacco, e- cigarette, or pharmaceutical industries
  • 3. Regulation for tobacco harm reduction 1. The problem is smoking 3
  • 4. Well researched toll of harm from smoking Smoking prematurely kills around 8 million annually more than obesity, alcohol, road accidents, drug misuse and HIV combined 4 Public Health England, Health Matters similar to COVID-19, but every year
  • 5. Smoking prevalence in Africa WHO (2021) 5 Published November 2021 South Africa Nigeria Ethiopia
  • 6. Smoking prevalence in Africa WHO (2021) 6 Published November 2021 South Africa Ethiopia Nigeria
  • 7. Declining prevalence but increasing population will increase African share 7 Africa
  • 8. Regulation for tobacco harm reduction 1. The problem is smoking 2. Smoke-free alternatives 8
  • 9. People smoke for the nicotine but die from the tar (1976) Professor Michael Russell 1932-2009 The central insight in smoking and health 9 Russell MJ. Low-tar medium nicotine cigarettes: a new approach to safer smoking. BMJ 1976;1:14303
  • 10. Smokeless tobacco Tobacco based Pure nicotine based Heated aerosol Unheated Vaping products Heated tobacco products Heat-not-burn Items are not shown to scale Oral nicotine products 10
  • 11. Royal College of Physicians on relative risk "Although it is not possible to precisely quantify the long- term health risks associated with e-cigarettes, the available data suggest that they are unlikely to exceed 5% of those associated with smoked tobacco products, and may well be substantially lower than this figure". 11 Royal College of Physicians. Nicotine without smoke: tobacco harm reduction London: RCP; 2016.
  • 12. Department of Health (England) on relative risk September 2022 12 McNeill et al. Nicotine Vaping in England, 2022 vaping poses only a small fraction of the risks of smoking
  • 13. Much lower Much lower Much lower Much lower Much lower Much lower The strongest evidence for reduced harm is reduced exposure 13 Shahab L, Goniewicz ML, Blount BC, et al. Nicotine, Carcinogen, and Toxin Exposure in Long-Term E-Cigarette and Nicotine Replacement Therapy Users. Ann Intern Med 2017
  • 14. Evidence from randomised controlled trials 14 There is highcertainty evidence that e- cigarettes with nicotine increase quit rates compared to NRT
  • 15. Evidence for beneficial population effect triangulates Also, user testimony And it is what you would expect!! 15 Professor Robert West, UCL. Presentation at SRNT-Europe 2019
  • 16. Regulation for tobacco harm reduction 1. The problem is smoking 2. Smoke-free alternatives 3. Policy and unintended consequences 16
  • 17. The public health mechanism 17
  • 18. Royal College of Physicians perverse unintended consequences 18 Royal College of Physicians. Nicotine without smoke: tobacco harm reduction London: RCP; 2016.
  • 19. if a risk-averse, precautionary approach makes e-cigarettes: less easily accessible less palatable or acceptable more expensive less consumer friendly pharmacologically less effective inhibits innovation then it causes harm by perpetuating smoking. Royal College of Physicians perverse unintended consequences 19 Royal College of Physicians. Nicotine without smoke: tobacco harm reduction London: RCP; 2016.
  • 20. 1. Prohibition of vaping and other smokefree products
  • 21. 1. Prohibition of vaping and other smokefree products Dr Harsh Vardhan received the award for spearheading the Government of Indias legislation to ban e-cigarettes and heated tobacco products in 2019.
  • 22. 1. Prohibition of vaping and other smokefree products 22 Today, the country is faced with a greater challenge, that of illegal traffic in tobacco and its products. So long as the demand within the country persists, it will continue to fuel the illicit market that has expanded since the ban of its sale in early 2000. Unfortunately, as studies indicate, Bhutanese youth are at the centre of this growing illegal trade in tobacco and its products. WHO Office Bhutan: The Big Ban: Bhutans journey towards a tobacco-free society, 2019
  • 23. 2. Banning e-liquid flavours 23
  • 24. 2. Banning e-liquid flavours Tobacco Fruit Dessert or pastry Choc, sweets Russell et al. vaping flavour preferences Russell C, et al. Changing patterns of first e-cigarette flavor used and current flavors used by 20,836 adult frequent e-cigarette users in the USA. Harm Reduct J. BioMed Central; 2018 24
  • 25. 2. Banning e-liquid flavours 25 The intended outcome: abstinence from nicotine, vaping, smoking and any other vice Using tobacco flavoured vape products instead of other flavoured products Accessing flavoured vapes via an illicit supply chain (a black market) Relapsing back from vaping to smoking both teenagers and adults Not switching from smoking to vaping and continuing to smoke Continuing to smoke or to start smoking as an adolescent because parents or adult role models smoke instead of vaping Using other tobacco or nicotine products hand-rolling tobacco, smokeless tobacco, heated tobacco, or new nicotine pouches Buying from foreign suppliers in person or via the internet and importing for personal use Buying from foreign suppliers to resell to others through informal networks Making and mixing their own flavours at home or buying or selling home-mixed flavours Using vapes that are made to look tobacco flavoured but have other flavours Using flavour agents for food, drink or aromatherapy for adding to unflavoured nicotine liquids Using flavours made for vaping but ostensibly marketed for another purpose Switching to cannabinoid (THC or CBD) vapes Initiating smoking instead of initiating vaping Adopting another risk behaviour that may be worse
  • 26. Friedman AS. A Difference-in-Differences Analysis of Youth Smoking and a Ban on Sales of Flavored Tobacco Products in San Francisco, California. JAMA Pediatrics. 2021 2. Banning e-liquid flavours Teenage smoking increased following an e-cigarette flavours ban in San Francisco Past-30-Day Smoking Trends Among High School Students Younger Than 18 Years
  • 27. 3. Banning advertising of vapes 27
  • 28. 3. Banning advertising of vapes 28
  • 29. 3. Banning advertising of vapes 29 Dont be socially irresponsible Dont target or feature children Dont confuse e-cigarettes with tobacco products Dont make health or safety claims Dont make smoking cessation claims Dont mislead about product ingredients Dont mislead about where products may be use Set standards avoid bans
  • 30. 4. Fear-based warnings This product contains nicotine which is a highly addictive substance. 30 Required by EU Tobacco Products Directive 40/14/EU
  • 31. 4. Fear-based warnings [Our findings] suggest that the TPD nicotine addiction e-cigarette health warning may reduce smokers' willingness to use, and likelihood of purchasing an e- cigarette. 31 Cox S, et al Messages matter: The Tobacco Products Directive nicotine addiction health warning versus an alternative relative risk message on smokers willingness to use and purchase an electronic cigarette. Addict Behav Reports, 2018
  • 32. This product is likely to be at least 95% safer than smoking cigarettes No product is completely safe, but use of this product is much less harmful than smoking 4. Fear-based warnings 32
  • 33. 5. Taxing safer products
  • 34. 5. Taxing safer products Reduce teen e-cigarette use by 2.7 percentage points, but that 2 in 3 teens who do not use e- cigarettes due to the tax would smoke cigarettes instead. .approximately a half million extra teenage smokers overall. raise the number of daily adult cigarette smokers by 2.5 million nationally and reduce adult e-cigarette users by a similar number. For every e-cigarette pod eliminated by an e- cigarette tax, more than 5.5 extra packs of cigarettes are sold instead Congress: raise e-cigarette taxes to a level comparable to cigarette taxes
  • 35. 5. Taxing safer products
  • 36. The solution: Risk-Proportionate Regulation Measure Cigarettes, hand-rolling tobacco and other combustibles Taxation Relatively high taxes Advertising Prohibit other than within trade Warnings Graphic warnings depicting disease Public places Legally mandated controls Plain packaging Yes Ingredients Control reward-enhancing additives Age restrictions No sales to under-21s Internet sales Banned Product standards Control risks and reduce appeal 36
  • 37. The solution: Risk-Proportionate Regulation Measure Cigarettes, hand-rolling tobacco and other combustibles Vaping, heated tobacco smokeless and oral nicotine Taxation Relatively high taxes Low or zero tax (sales tax only) Advertising Prohibit other than within trade Control themes and placement Warnings Graphic warnings depicting disease Messages encouraging switching Public places Legally mandated controls Up to the discretion of the owner Plain packaging Yes No Ingredients Control reward-enhancing additives Blacklist material health hazards Age restrictions No sales to under-21s No sales to under-18s Internet sales Banned Permitted with age controls Product standards Control risks and reduce appeal Control risks 37
  • 38. Regulations for tobacco harm reduction 1. The problem is smoking 2. Smoke-free alternatives 3. Policy and unintended consequences 4. Innovation (and its enemies) 38
  • 40. A technology transition - electricity
  • 41. Innovation and its enemies Claims about the promise of new technology are at times greeted with skepticism, vilification or outright oppositionoften dominated by slander, innuendo, scare tactics, conspiracy theories and misinformation. The assumption that new technologies carry unknown risks guides much of the debate. This is often amplified to levels that overshadow the dangers of known risks. Juma C. Innovation and Its Enemies: Why People Resist New Technologies. Oxford, New York: Oxford University Press; 2016.
  • 42. Thankyou! Counterfactual clivedbates@gmail.com www.clivebates.com @clive_bates 1. The problem is smoking 2. Smoke-free alternatives 3. Policy and unintended consequences 4. Innovation (and its enemies) Regulation for tobacco harm reduction

Editor's Notes

  1. Vaping products Top row shows: 1st generation cig-a-likes 2nd generation ego or pen type devices 3rd generation tanks / mods type Bottom row shows Large electronic hookah Small shisha pipes Electronic pipe there are many other configurations Heated tobacco products sometimes referred to as heat-not-burn to distinguish between combustible products Shows the iQOs, Ploom and Glo products Novel nicotine products - shows Nicoccino a nicotine containing film Zonnic a range of nicotine products lozenges, gum etc Voke a cold aerosol (approved but not marketed) Niorette cross-over NRT Smokeless tobacco Snus Moist snuff Tobacco-based lozenge